Coroner Finds Significant Failings Led To Avoidable Death

Now Law Firm Irwin Mitchell Urges NHS To Review Procedures After Patient Dies Following Two Separate Delays In Treatment

04.05.2011

The brother of a woman who died from a brain abscess has criticised two South Yorkshire hospitals for “leaving his sister to die” – after it emerged a communication mix-up left her waiting four days for a transfer to undergo emergency surgery.

An inquest into the death of Margaret Hardwick today found that she stood a 90 per cent chance of surviving the abscess if she had undergone treatment quickly. The inquest also highlighted a wider issue surrounding the diagnosis of brain lesions, which was described by the Coroner as being “very significant nationally”.

Miss Hardwick, 72, from Brierley, in Barnsley, was a patient in Barnsley District General Hospital when it was discovered she was suffering from the abscess in November 2009. Although doctors gave instructions for her to be transferred to Royal Hallamshire Hospital for treatment “without further delay”, a communication mix up meant that the transfer was not arranged, instead Miss Hardwick was left on the ward until she died four days later.

Medical law experts at Irwin Mitchell, representing the family, are now urging the NHS to review its communication and transfer procedures to make sure lessons are learnt to prevent similar cases in the future.

Ian Murray, a specialist solicitor in the medical law team at Irwin Mitchell, said: “Once it was identified that Miss Hardwick needed emergency treatment, a four day delay for moving her between two hospitals is totally unacceptable.

“This case highlights how basic errors so often have a tragic and devastating effect on the lives of patients and their families. Miss Hardwick was the victim of a serious failure in communication and it is vital that the NHS conducts a thorough review of its procedures for organising hospital transfers to ensure a suitable protocol is in place.

“Our clients want to know that lessons are being learned from their tragic case and want reassurances that this situation cannot happen again. Irwin Mitchell has repeatedly called for improvements in patient safety and will continue to campaign on our clients’ behalf.”

Miss Hardwick’s brother, David, said: “Margaret’s death has left our whole family devastated. She was like a grandmother to my grandchildren and without her around there is a huge void in our lives.

“It is extremely distressing to hear that Margaret was left for four days without treatment which could have saved her life, all because of a basic mix up in communication.

“It’s like they just left her to die, and we sincerely hope the NHS takes prompt action to prevent this from happening to anybody else. It just makes us angry to know that Margaret’s life could, and should, have been saved.”

An inquest into Miss Hardwick’s death which concluded on 4 May 2011 revealed that following diagnosis of a brain abscess requiring emergency treatment, the on call team at Sheffield failed to organise her transfer so that treatment could take place. The coroner also heard evidence that if Miss Hardwick had been treated at an earlier stage, Miss Hardwick would have stood a 90 per cent chance of surviving. He recorded a narrative verdict.

Radiologists at Barnsley District General initially thought Miss Hardwick’s lesion was a malignant tumour, but were unable to differentiate this from a brain abscess. Two days after the scan was ordered a neuroradiologist reviewed her MRI scan and was able to identify it was an abscess requiring emergency surgery.

HM Coroner Christopher Dorries revealed he will now write to the Chief Medical Officer to highlight the ease with which MRI can be used to distinguish brain abscess from brain tumour, and the apparent lack of knowledge of this within the general radiological community. Irwin Mitchell hopes this will massively improve patient safety.

Ian Murray added: “When Miss Hardwick’s MRI scan was first reviewed by radiologists they were able to identify a mass on her brain. However, because general radiologists are often unable to differentiate between abscesses and tumours, they were unable to diagnose the abscess until it was reviewed by a neuroradiologist two days later.

“The key difference between an abscess and a tumour is that an abscess is an infection requiring immediate treatment, whereas a tumour takes longer to develop with more time for treatment.

“By using a technique called diffusion weighted imaging it is actually extremely simple to differentiate between the two, and we urge the NHS to provide training in its use to radiologists across the country. This will help to save valuable time in the future and will greatly improve patient safety. It’s an opportunity to save more people’s lives.”

Background

Miss Hardwick was admitted to Barnsley Hospital after she collapsed at her home on 30 October 2009. Doctors initially diagnosed a minor gastric illness or virus, but after she was reviewed and sent for an MRI scan on 2 November it was decided to have an MRI scan, which found that was probably suffering from a malignant tumour on her brain.

On 3 November 2009 Miss Hardwick was given initial treatment for the tumour but at a meeting on 4 November 2009 the neuroradiologist raised concerns that it was an abscess which the tumour could be life-threatening if it was to rapidly increase in size.

The decision was taken to transfer Miss Hardwick to Sheffield “without further delay”, but a breakdown in communication resulted in the transfer not being organised.

On the 7 November, four days after the lesion had first been discovered, and after Miss Hardwick’s condition had significantly deteriorated, further scans then revealed the abscess had grown quickly, increasing the pressure on her brain. Miss Hardwick’s condition continued to deteriorate and she sadly died on 8 November, aged 72.